24 March 2010

We all know these witches. They are the people who rudely interrupt your ward round to complain about a tie or a bangle that they deem a health hazard. Despite their rudeness and God-given right to throw abuse at hard-working staff, Dr Grumble complies fully with their wishes. Who would want to cross swords with a witch? Witches are powerful people. And they can caste spells.

Plainly others feel differently. Only yesterday Dr Grumble was told to tell one of his staff off about her attire. That is a new approach. Witches know they are despised so they try to get Dr Grumble to do their dirty work for them. Dr Grumble commands more respect than a witch. Not that that is difficult. Grumble dutifully passed on the complaint. The young doctor concerned took no notice. No notice whatsoever. Dr Grumble was not altogether surprised because he has seen this behaviour before. When the coven makes its wishes known, heels are dug in and the instruction is blatantly ignored. There is something very wrong with an organisation when staff react in this way.

You might think that Dr Grumble's charges must be a rebellious lot but it is not the case. Dr Grumble's own instructions on patient care are followed to the letter. There is never any argument about who is in charge and who knows best. We all know that Grumble could be wrong but we all also know who has to carry the can. What Grumble requires to be done is done. But edicts originating from witches are studiously ignored. The difference in behaviour is quite striking.

32 comments:

A. Medstudent
said...

I like this post a lot! I have a theory that infection control is a lot like terrorism: nobody denies there is a risk, but the risks are overstated in order to give more power to people who would otherwise find themselves in less lofty positions.

I'm not sure what the evidence base is for many of their edicts (Ties? Seriously?) as I have far better things to do than trawl medline for [ti]"formal wear" AND "deadly threat to humanity". However, I understand that campaigns against flowers and sitting on patients' beds have no evidence. That means they can make anything up and enforce it through the usual tactics of bullying and hostility.

Did you ask the witch in question to say it to the person directly? Seems a bit cowardly if they dont do it themselves. Sure I've read somewhere Medstudent that sitting on the bed makes the patient feel there having more time spent on them.Renationalising cleaning may be a good idea

No. I didn't ask the witch to do her own dirty work. There are some battles worth fighting and there are some that are just not. The whole episode reminds me of the sort of battles we used to have at school about the length of our hair and drain pipe trousers - at least those were the issues in my day. Why school authorities get so heated about these things I have no idea. There are things that matter and things that don't but, curiously, human beings squabble over things that really don't matter.

Nevertheless you can see which side I am on. And probably the junior doctors know full well too. I think what makes them angry is that we are often struggling against the odds to control infection and the reality is that we get bludgeoning from the witches rather than proper help to control infection from the management. For example, we have inadequate numbers of single rooms and as a result we have to scatter infectious patients around the hospital. This spreads the infection from ward to ward and then we have to go to visit outliers risking spread of infection yet again. Chockablock hospitals with beds too close together receiving new occupants before they are cold and patients being shoehorned into wards away from the team that cares for them are additional factors that are a recipe for the spread of infection. Proper isolation wards (or even hospitals) are a thing of the past.

We all know that the management are hell-bent on blaming doctors for infection control problems. They do this to deflect attention from their own gross inadequacies. We should be demanding infrastructures conducive to infection control. Instead they are hectoring us over things that are probably neither here nor there.

Its a shame managers dont thing that doctors (and other professional) care about infection control. We do know why its bad for patients

I doubt they would be rude to visitors coming outside of visitors hours for instance. Its a lot easier to bully doctors. I remember reading about managers getting people to give out yellow cards if they saw someone who had not washed there hands, its unlikely they would do this to visitors.

An interesting analogy to school, but doctors are not children - kids dont take pride in there appearance so I can kind of see where school authorities are coming from. They need to set the boudary for the kids. Healthcare professionals take pride in what they wear and how they look, so authority giving them rules is not needed.

Bed shortages are just going to get worse, although its been proven a bed surplus cuts the risk of infection

A leaked government internal review dating back to 2004 and supported by subsequent research shows that when bed occupancy is higher than 90 per cent, infection rates are more than 40 per cent higher that when just 85 per cent of beds are occupied. Many hospitals are already running at or near 100 per cent. Yet this has been ignored by the Department of Health and NHS officials because it is in conflict with current policies for reducing bed numbers.

As you may have spotted on Dr Crippen's blog just before it went off-air, up in Dr Aust's neck of the woods they are gettin' down musically on the subject of hygiene.

Talking of misguided rules, Jr Aust's primary school now has compulsory school uniform following a rather dodgy "referendum" that would not have cut it with any UN Poll Observer. Mrs Dr Aust, from her European perspective, thinks compulsory uniforms in primary school are a classic example of a "thing that doesn't matter", but they seems all the rage in British primary education.

Personally I think the answer is that primary kids wearing uniforms is being taken by head teachers and the Govt as a surrogate end-point for something that does matter, like pupil behaviour. Whether it is in any way a useful surrogate end-point for such is a different matter.

I would have thought there was far more infection risk by allowing nurses and other staff to wear their uniforms outside the hospital and travelling to and from work. As a neighbour, a retired nurse, points out, when she was in training she was threatened with dismissal because she was seen visiting a shop next door to the hospital during her lunch break whilst wearing her uniform!

The issue of freshly laundered uniforms confined to the hospital is another management failure. Some of us can still remember when the hospital used to supply beautifully clean starched white aprons for the nurses and even a clean white coat for the doctors.

If you have ever visited a pharmaceutical company you may have entered the production area via an immaculate changing area where even casual visitors don a beautifully clean new outfit. Of course the situation in a hospital in not the same because the germs are already inside the place brought their on the patients. Nevertheless we could do better on the provision of laundered overalls and changing rooms.

One also questions whether modern Laundry practices are as good as they used to be. The latest detergents may superficially clean at lower temperatures, thus saving energy, but are they effective in killing all the germs as old fashioned boiling? Have any tests actually been carried out?

What the NHS needs is for it to go back to basics. It has since when I first joined in 2003 become steeped in managerialism and bureaucracy. Like I have said before regarding the NHS it is and won’t be a simple matter of firing the staff involved in the managerialism and bureaucracy; because they have craftily hired trained staff nurses and sisters to do the job. So any removal of these staff will instantly result in hysterical “sacking of frontline staff” style headlines.

These departments are given grandiose names like Releasing Time to Care Team and Infection Control and generally either do the opposite what their names imply or are a variation of that name. Releasing Time to Care is a department that spends its time being condescending and patronising to staff along with producing many useless charts and graphs measuring minutiae of ward activity.

Infection control are similar; they do not actually clean anything and in fact spend most of their time sending out “surveillance teams” (spies to you and I) with tick sheets to observe the ward staff doing the work. They should be called Infection Monitoring.

All these departments are self perpetuating of course, most of their solutions boil down to more paper work and monitoring.

At a hospital not a million miles from me, the infection control bods are asleep about the real issues. The loos nearest the main entrance are equipped with elbow taps which are installed......back to front, elbows to turn on, cleaned hands to turn off....!!! One of the elderly care wards had the same problem when I last went there. On another wing with two wards there is a common door from the lifts/corridor. These double doors, which open outwards, are kept open at all hours by being hooked back against the walls...the hand gel containers are installed on the outer side of the doors, which are of course ....yes, you guessed it, against the wall and inaccesible!!!

lots of signs telling folk to wash their hands, yet in many gents in one bigh hosptial i can name there are about 6 sit down cublicles, another 6 urinals, and er one hand wash basin for everyone to wash their hands

now agressive signs to wash your hands are plainly stupid when there are not enough wash basins in the bogs for the number of customers using them

any half decent organisation would put more hand basins in and stop dicking around with nanny state signs

Without meaning to sound rude; hospitals are filthy. When my girlfriend gave birth recently at West Middlesex Hospital the wards were dirty, soiled linen was left lying about the place and it was generally a bit of a dump. Many members of staff lacked basic hygine skills, like washing their hands properly.

Hospitals are infested with disease - in fact a few years ago my dad went in for a heart op (all went very well thanks to excellent staff) but he came out with MRSA.

The long and short of it is this: if you lot spent a bit more time being clean and a lot less time moaning then y ou wouldn't have the infection control witches.

I'm sorry if this sounds rude, but the more postings I read from doctors the more pompous and self-important you all start to sound. Most medical doctors who blog spend a lot of time criticising everyone else in the NHS and making insulting comments.

Get your own house in order. Many hospitals I've seen would be closed down if they were restuarants because they are so dirty.

By the way, I work in a office that has ntohing to do with hospitals, medicine, etc.

It's not a bad idea to moan. Here is a moan on the topic of MRSA written by no less a person than Dr Grumble. It is the most read post on the blog. And since it was first published the government has made quite a few improvements in its attempts to control MRSA. Doubtless somebody in the DoH is reading the Grumble blog.

Doctors get fed up with being blamed. Don't be taken in by the rhetoric that it is all our fault. If managers had listened to doctors as they did in Norway, Sweden and elsewhere instead of waiting for the moans of Dr Grumble we would not be in the trouble we are in now. We want infections to be controlled but it is very frustrating when you find insurmountable problems with the infrastructure that nobody seems to want to address (though, as it happens, a real effort has been made in the Grumble hospital and things are very much better than they were).

dont get taken ill in basildon, sunderland or coventry needing a hospital admission dr G, you will see the true meaning of dirt if you are unfortunate enough to suffer this, i list these as hospitals i see the shit literally allover the place regularly

make me laugh that some of the community nurses refuse to acutally visit one of these hospitals as they regard it as too dirty and likely to pass on nasty things to them which they dont want to spread amongst the community

when the local nurses who are fit and healthy avoid the hospital like that you know its shit

It wasn't that long ago that the NHS had an unenviable reputation for some of the highest rates of hospital acquired infection in Europe.http://www.telegraph.co.uk/health/3303688/The-truth-about-NHS-hospitals-hygiene.html

Meanwhile studies demonstrated poor compliance with even the most rudimentary risk reduction measures (hand washing, etc) while antibiotics continued to be pumped out on a near industrial scale.

Sadly, leaving clinical responsibility to individuals at the bedside failed to achieve acceptable standards (leaving aside other important factors, like insane bed occupancy l levels, for the moment).

In short, the NHS, up until fairly recently, was repeating mistakes that had driven Ignaz Semmelweis to the edge of sanity;http://en.wikipedia.org/wiki/Ignaz_Semmelweis

But unlike today's lot, at least Semmelweis's Austrian contemporaries could claim a certain degree of ignorance when it came to the relationship between certain hospital practices and the effects these practices had on the welfare of patients.

Being nagged about a tie, or wrist watch might be a bit of a nuisance but these minor personal infringements hardly bear comparison with the many 1,000s (and perhaps 100s of thousands) who have been killed or harmed by a preventable infection?

Although I think that infection control is in essence a good idea, when some of the "solutions" have absolutely no scientific base, I find it hard to reason that "removing your watch" does anything other than irritate staff and transfer the bugs to your new fob watch instead.

I got hammered by the coven for sitting on a bed recently, infront of a patient and his wife. For what exactly? There is no logic nor scientific evidence that sitting on beds raises the risk of infection. After said coven member left, the patient started fuming about how pointless bureaucracy is ruining the NHS. And this was a patient saying it for a change! He said he would have told me to sit back on the bed out of principle but didn't want me to get into trouble. The poor wife was flabbergasted that one staff member would treat another with such hostility.

It is rubbish like this that gives the coven a bad name. Do the ends really justify the means, especially when the ends could so easily be met by a much more pleasant approach?

I love these idiots. One stopped me on the ward the other day, and said:

'why are you wearing a watch?'

I asked her who she was. She explained that she was an infection control nurse.

'to tell the time' I said.

She looked baffled.

'your watch can carry infection' she said.

'Although wrist watches like any other item in the known universe may have surface contamination, do you have any evidence to show that analysis of what is a surrogate marker in any case leads you to conclude that wearing a watch is a clinical risk to patients?'

Silence, and look of bafflement. She left.

Now, during a 'patient care episode' I do remove my watch. I might scratch someone during handling. That is a good reason. Dictats from morons are not.

Of course, the REAL problem that is not mentioned is that if you run a hospital at over 80% occupancy with no time for proper bed and bed space cleaning, your infection rate goes through the roof. But we can't talk about that, as closing beds is government policy as we are now more 'efficient'

Medic Mouse - according to this report "four out of 10 Irish doctors and medical students are carrying out clinical procedures without cleaning their hands".http://www.timesonline.co.uk/tol/news/world/ireland/article5627746.ece

The report was published one year after an HSE advertising campaign aimed at reminding medical staff to wash their hands - yet the campaign was dismissed as “insulting” by one of Ireland’s most senior A&E doctors. Stephen Cusack from Cork University Hospital said many medical personnel were offended by the adverts, and that the HSE would be better off directing its funds at overcrowding, claiming “both doctors and nurses are well aware of the need for washing hands”.

So the days of gently trying to remind staff to adhere to basic hygiene measures has given way to a more strident approach, perhaps due to the unrelenting body count - or put another way the gap between what some clinical THINK they do, and what they actually do DO remains unacceptably wide.

It's a very strange thing that the coven are very concerned about wrist watches and ties but unfazed by stethoscopes. These fomites dangle like ties and actually touch patients. They can carry MRSA amongst many other organisms. And many studies have shown that staphylococci can survive in a dry environment for long periods.

Equipment used by nurses such as blood pressure cuffs and oximeters may also go from patient to patient. C difficile spores are difficult to eradicate from this sort of equipment as they will even survive bleach.

A lot of the work of the coven is about making a big song and dance so that it looks as if something is being done while skating around the real issues that need addressing but the witches do not even seem to be aware of. Simple things like gelling your hands will keep them happy but C difficile spores just get stored in the gel for the next patient.

Dr Grumble has actually been complemented on his adherence to the hygiene protocols but there is no doubt that doctors take great offence when they are challenged on these things and can be very stubborn. Why this should be is not entirely clear. Part of the problem may be that many doctors suffer from the Omo syndrome - or a belief that they are clean. Another issue may be that nobody likes to be told they are dirty. And certainly they don't like to be accused of spreading infection. And many doctors do not see the evidence to support what they are being told to do.

For things like hand washing there is very good evidence and I do wonder whether the focus should have been on things that really matter rather than things that probably don't. Perhaps that way the infection control people who plainly have much more time than people like Nurse Anne would command more respect. A further issue is the way these things are done. The scrubbing of commodes is certainly a very important task but you are not going to gain much respect from people like Nurse Anne who plainly care about their patients if you demand something that they plainly haven't got time to do.

Probably it is apparent to us all that money has been thrown at infection control teams who go around telling hard pressed people like Nurse Anne to scrub. These people never do any cleaning themselves. And they acquire more and more funding to deal with the problem of hospital infection when the money might have been better spent on another pair of hands to help poor Nurse Anne scrub her commodes.

It is unclear from this article what the real issue is. The hospital seem to claim it is a patient safety issue related to a patient grabbing the offending cross but it is difficult to see how that could hurt a patient unless it is an infection control thing.

There are battles worth having and battles that are not worth having. It is very odd that neither side is prepared to back down on this one. The nurse and the bishops are plainly spoiling for a fight. The expedient thing for the hospital authorities to do in this case would be to give this particular nurse a special dispensation based on her idiosyncratic strong religious views. It is odd what a rare commodity common sense is.

The bishops have timed their letter to the press cleverly and are plainly trying to influence the outcome of the employment tribunal. How much is this going to cost? What is the point? Does it really matter? Are Christians really being persecuted by the NHS. There's a whole chapel in the Grumble hospital!

It's too late now but Dr Grumble's advice to the nurse is to do what the witches want and settle for wearing the cross at home. Although witches are pagans this seems to be very little to do with religious persecution but as, anonymous says, it is just the mild persecution we all get at work. Witches like power and control. Let them have it. Let them follow their sometimes misguided beliefs. It really doesn't matter. This is a story about pettiness.

The Grumble view on this one is that it is difficult to defend the line taken by either side in this dispute. As usual only the lawyers will benefit from this.

'it is just the mild persecution we all get at work. Witches like power and control. Let them have it. Let them follow their sometimes misguided beliefs. It really doesn't matter. This is a story about pettiness.'

Right analysis, wrong response IMHO. It is imperative that doctors especially fight what is essentially the pursuit of mediocrity and the lowest common denominator in health care. Our patients deserve no less. The removal of the professional status of the doctor and ward nurse in favour of the 'small brain fat arse brigade- as a colleague of mine so elegantly puts it, is what is ruinig health care. I fight this whnever I can.

An always great question:

Do you have any evidence for this? That has been subject to peer review in a reputable journal (believe me there is bugger all).

There is no doubt that we have been trampled upon and that the profession has been ignored even over very important matters. And we have made the mistake of thinking some things didn't matter or were so daft that they wouldn't come to pass when they did matter and they did come to pass. But battling over the odd tiny cross that a nurse wants to wear really is ridiculous.